Category Archives: Community

William R Brieger (wbriege1@jhu.edu) and Gilbert Burnham (gburnha1@jhu.edu) of The Johns Hopkins Bloomberg School of Public Health, Department of International Health presented ideas about mapping and integration of neglected tropical diseases and malaria interventions at the Malaria World Congress, Melbourne, Australia, July 2018

Overview: Lymphatic Filariasis (LF) and Malaria share a common vector in sub-Saharan Africa. Mass Drug Administration (MDA) is a strategy that is common to both diseases. Where the diseases overlap there is the potential opportunity to coordinate both vector control and MDA to achieve synergy in program results. The example of Burkina Faso, supplemented with information from Ghana, serves as an example of what could be integrated and what actually happens.

Background: Thirty years ago then veterinary drug, ivermectin, was found effective in controlling neglected tropical diseases (NTDs), specifically two human filarial diseases: onchocerciasis and lymphatic filariasis (LF). The drug manufacturer donates 300 million treatments annually to eliminate both diseases. Since then, annual community based mass drug administration (MDA) efforts have resulted in millions of treatments in endemic countries and great progress has been made toward elimination of transmission. Through observation and experimentation, ivermectin was found to kill malaria carrying mosquitoes when they bite people who have taken ivermectin making it a useful tool for vector control.

CHWs in Burkina Faso demonstrating how to measure height to determine ivermectin dosage

Community Health Workers’ Role: Current research is examining how dosing and timing of treatments may impact national malaria vector control efforts. Comparing maps between malaria and LF can be a starting point for adapting ivermectin MDAs for malaria vector control. Burkina Faso MDAs are operationalized by community health workers (CHWs) who are part of a national program that provides treatment for common illnesses and also conducts village level onchocerciasis and LF MDAs. Vector Control with Long Lasting Insecticide Treated Nets In most of rural Africa, malaria and lymphatic Filariasis are co-endemic and share the same anopheles mosquito vector.

However, that does not mean that there is a coordinated effort to plan distribution of LLINs despite the fact that the intervention meets the needs of both disease control efforts. The current NTD programs in Burkina Faso and Ghana focus on Preventive Chemotherapy (PCT) delivered through Mass Drug Administration (MDA). Vector Control is seen as essential in areas co-endemic with LF, Loa loa and Malaria – mapping helps identify priority areas for vector control.

Vector Control by Chance: In Ghana, the NTD/LF elimination program was unaware of the LLIN coverage data available in the NMCP housed in an adjacent building. This illustrates the lack of collaboration between the two programs. Thus where — and if — vector control benefits the reduction of both diseases, it is often by chance where LF is concerned. The International NGO, The Carter Center, may be the only one that includes vector control as part of its programming for both malaria and LF in Nigeria. This practice should be replicated by other partners and country programs where possible.

Mass Drug Administration: MDA is the major strategy for control of five PCT diseases in the NTD program, and LF is one of those. Currently MDA anti-malarial drugs has been considered in limited situations in countries where there are areas that have very low transmission In the future countries may consider research that shows mosquitocidal effects of Onchocerciasis and LF MDAs with ivermectin. Otherwise for malaria, a special intervention called Seasonal Malaria Chemoprevention (SMC) is used in an MDA-like approach to reach young children in the African Sahel during high transmission months. In both cases, existing cadres of (usually volunteer) community health workers are the front line providers of MDA.

Burkina Faso LF Map from ESPEN: Mapping shows 10 of 70 health districts are currently doing LF MDA, though all have done it. Thus CHWs in all districts are experienced in ivermectin MDA. The malaria map shows that two-thirds of districts have a malaria incidence of 400/1000 or more while 14 have lower incidence. There is an overlap between current LF MDA districts and higher incidence malaria districts Both LF and Malaria Program Coverage can be seen to overlap in [program maps.

Ghana CHWs explain how they conduct MDA

Ghana Experiences: Ghana provides a contrasting example. There five regions in central Ghana that are mostly non-endemic for LF but do have moderate malaria transmission In the south two regions with former LF MDA activity overlap with higher malaria endemicity While four northern regions have lower malaria parasite prevalence, they do have current and recent LF MDAs Community Directed Distributors work with LF MDA in Ghana

Conclusions: Malaria elimination will need a mix of strategies to be successful. Therefore, it is not too early for malaria and NTD program managers, as well as their respective donors, to begin comparing maps to identify possibilities for adapting ivermectin MDAs for malaria vector control. Even though one endemic disease is nearing control or elimination, the infrastructure put in place to accomplish this can be mobilized for other disease control efforts – as long as we map where interventions and resources have been targeted.

Burkina Faso celebrated World Malaria Day with pledges to Defeat Malaria on 25th April 2018. Dr Ousman Badolo. Technical Director of Jhpiego’s USAID/PMI Supported Improving Malaria Care (IMC) Project describes below the event in the village of Kamboinsin, not far from the capital, Ouagadougou. Ibrahim Sawadogo from IMC provided the photographs.

The day started with a proclamation of malaria day from Burkina Faso’s President, Roch Marc Christian Kaboré, to his assembled cabinet and the press. The president recognized that malaria is still a major public health issue in the country, and while deaths are decreasing, the incidence of malaria is not. The President called for a greater commitment of resources by all partners to insure that malaria can be defeated in Burkina Faso by 2030.

Kamboinsin village in Sig-Noghin Health District was the site of further observances organized by the National Malaria Control Program, later that afternoon. This district was chosen because of having among the highest incidence rates for malaria in the region. Many partners set up booths to share their work in malaria with partners and citizens of the district. Included were three research centers (Centre Muraz, CNRFP and IRD), and three USAID programs supported by the President’s Malaria Initiative in Burkina Faso (Procurement and Supply Management [PSM], IMC and VectorLink), among others.

During the program both the Minister for Health and the US Ambassador spoke. The Minister highlighted the main strategies that Burkina Faso is employing to reduce and eliminate malaria including regular use of insecticide treated nets (ITN), seasonal malaria chemoprevention, Intermittent Preventive Treatment in Pregnancy (IPTp), Prompt and Appropriate Case Management and other Vector Control Strategies.

The US Ambassador shared a real-life story of a pregnant woman who during her current pregnancy decided to register early for Antenatal Care (ANC) as encouraged by the IMC project. She was able to get several doses of IPTp as required as well as obtain an ITN on her first visit, unlike in her previous pregnancies.

Entertainment was provided by the comedian Hypolythe Wangrawa (alias M’ba Bouanga) who presented a sketch involving his ‘son’ who was not encouraging his wife to attend ANC and receive malaria prevention services. M’ba Bouanga chastised the son and an actor playing a midwife explained to the family the value of attending ANC and preventing malaria. Singers Maria Bissongo, Miss Oueora and Aicha Junior provided the audience with a song that embodied a variety of malaria prevention and care messages.

A highlight of the occasion was recognition of high performing health districts in the country. They were judged on criteria including good management of malaria commodity stocks, reduced case fatality rates, use of diagnostic tests to confirm malaria before treatment and coverage of at least three doses of IPTp. Four districts were given awards, Titao, Thyou, Boussouma and Batie, while Charles de Gaul Pediatric Hospital was also recognized.

Around twenty years ago the course of malaria changed with the holding of the first MIM, also in Dakar and the establishment of the Roll Bank Malaria (RBM) Partnership. These were followed in short order by the Abuja Declaration that set targets for 2010 and embodied political in endemic countries, as well as major funding mechanisms such as the Global Fund to fight AIDS, TB and Malaria. This spurred what has been termed a ‘Golden Decade’ of increasing investment and intervention coverage, leading to decreasing malaria morbidity and mortality. The Millennium Development Goals provided additional impetus to reduce the toll of malaria by 2015.

On Facebook Live yesterday Dr Alonso talked about that ‘Golden Decade.’ There was a 60% decrease in mortality and a 40% decreases in malaria cases. But progress slowing down and we may be stalled at a crossroads. He noted that history show unless accelerate efforts, malaria will come back with a vengeance. Not only is renewed political leadership and funding, particularly from affected countries needed, but we also need new tools. Dr Alonso explained that the existing tools allowed 7m deaths be diverted in that golden decade, but these tools are not perfect. We are reaching limits on these tools such that we need R&D for tools to enable quantum leap forward. Even old tools like nets are threatened by insecticide resistance, and research on alternative safe insecticides is crucial.

Dr Alonso at MIM pointed to the worrying fact that investment in malaria overall peaked in 2013. Investment by endemic countries themselves has remained stable throughout and never gone reached $1 billion despite advocacy and leadership groups like the Africa Leaders Malaria Alliance. The 2017 WMR shows that while 16 countries achieved a greater that 20% reduction in malaria cases, 25 saw a greater that 20% increase in cases. The outnumbering of decreasing countries by increasing was 4 to 8 in Africa, the region with the highest burden of the disease. Overall 24 African countries saw increases in cases between 2015 and 2016 versus 5 that saw a decrease. A review of the Demographic and Health and the Malaria Information Surveys in recent years show that most countries continue to have difficulty coming close to the Abuja 2010 targets for Insecticide treated net (ITN) use, prompt and appropriate malaria case management and intermittent preventive treatment of malaria in pregnancy (IPTp).

The coverage gap is real. The WMR shows that while there have been small but steady increase in 3 doses of IPTp, coverage of the first dose has leveled off. Also while ownership of a net by households has increased, less than half of households have at least one net for every two residents.

In contrast a new form of IPT – seasonal malaria chemoprevention (SMC) for children in the Sahel countries has taken off with over 90% of children receiving at least one of the monthly doses during the high transmission season. Community case management is taking off as is increased use of rapid diagnostic testing. Increased access to care may explain how in spite of increased cases, deaths can be reduced. This situation could change rapidly if drug resistance spreads.

While some international partners are stepping up, we are far short of the investment needed. The Gates Foundation is pledging more for research and development to address the need for new tools as mentioned by Dr Alonso. A big challenge is adequate funding to sustain the implementation of both existing tools and the new ones when they come online. Even in the context of a malaria elimination framework, WHO stresses the need to maintain appropriate levels of intervention with case management, ITNs and other measures regardless of the stage of elimination at which a country or sub-strata of a country is focused.

Twenty years after the formation of RBM and 70 years after the foundation of WHO, the children, families and communities of endemic countries are certainly ready to beat malaria. The question is whether the national and global partners are equally ready.

The Concept of Primary Health Care (PHC) was formalized in 1978 when The World Health Organization and UNICEF convened a major conference in the then Alma Ata in Kazakhstan. The resulting Alma Ata Declaration resulted in advocacy for Health for All, which had evolved into Universal Health Coverage. The Declaration outlined important principles such as community participation in health care planning and delivery, promotion of scientifically sound and acceptable health interventions, the use of community-based health workers (CHWs), and addressing the common endemic health problems in each community. One of those endemic problems common to a majority of communities in Africa is malaria. Now in 2018, 40 years after the Alma Ata Declaration we explore how malaria has progressed within the context of PHC.

The Roll Back Malaria Partnership (RBM) began in 1998, 20 years after Alma Ata. When RBM convened a meeting of African Heads of State in 2000 the resulting Abuja Declaration set targets for major malaria interventions of 80% coverage by 2010. The Abuja Declaration reflected principles of Alma Ata when it called on all member states to undertake health systems reforms which will:

Promote community participation in joint ownership and control of Roll Back Malaria actions to enhance their sustainability.

Make diagnosis and treatment of malaria available as far peripherally as possible including home treatment.

Make appropriate treatment available and accessible to the poorest groups in the community.

By 2011 reality intervened. WHO reported that “In the 10 years that has passed since the Abuja Declaration, there has been progress towards increasing the availability of financial resources for health at least in terms of dollar values. However, there has not been appreciable progress in terms of the commitments the Africa Union governments make to health, or in terms of the proportion of GNI the rich countries devote to Overseas Development Assistance.” Since that time funding from international and bilateral donors has leveled, such that there is even greater need for malaria endemic countries to step forward and guarantee access to malaria prevention and treatment services are available through PHC at the grassroots. Such access needs to move beyond removing barriers to making malaria interventions attractive to the community.

Community Health Workers in Nigeria are trained to provide malaria community case management

Christopher and colleagues looked to the community and examined how response to malaria and other childhood illnesses were faring 30 years since Alma Ata. After they reviewed seven studies of community health workers they concluded that “CHWs in national programmes achieved large mortality reductions of 63% and 36% respectively, when insecticide-treated nets and anti-malarial chemoprophylaxis were delivered, in addition to curative interventions.” (They found little evidence of the effectiveness of these community interventions on pneumonia and diarrhoea.) The challenge they saw was the ability of countries to move beyond successful studies to scale up and sustain community malaria control interventions to the national level and thereby reap the full promises and benefits of PHC.

Others continue to advocate for a community role in achieving malaria goals through PHC. Malaria Consortium has looked at the position of malaria control within the context of Community Based PHC (CBPHC) and the use of CHWs as a means for revisiting Health for All.

Community donates a house in Western Region Ghana to serve as CHPS Compound where malaria services are provided to the community

Ghana’s community-based health planning and services (CHPS) program aims to make primary care accessible at the grass roots. CHPS compounds are small clinics in space usually donated by the community, staffed by community health officers who oversee community based agents (CBAs) and other community volunteers who treat and prevent malaria through integrated community case management. Countries have also build on the community directed intervention approach pioneered by the African Program for Onchocerciasis Control to ensure malaria interventions are delivered through community community planning and action.

Controlling and eventually eliminating malaria will certainly go a long way toward helping achieve Health for All. On this 40th Anniversary year of Alma Ata it is time to ensure that all malaria endemic countries and malaria donors revisit the basic philosophy of community action and participation and ensure that these principals guide us to accessible and sustainable malaria programming by the community “Through their Full Participation.”

George Mwinnyaa grew up in a small village in Ghana, West Africa. “I witnessed the death of several people including my siblings and my father. I became a health volunteer and later a community health worker.” George presented at the Johns Hopkins University TEDx event on 10 March 2018. Below are excerpts from that talk focused on his experiences in malaria interventions in Ghana and reflects on numbers found in public health interventions and questions what these numbers really mean to community members on the ground. George is currently an MHS student studying infectious disease epidemiology at the JHU Bloomberg School of Public Health.

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I have always been very skeptical with numbers, particularly numbers that indicate program accomplishments from the developing world. Whenever I see numbers reporting a problem such as the mortality relating to malaria, Pneumonia, or diarrheal diseases- it puzzles me because these are all diseases that have received great attention, and there have been many interventions implemented. Yet these problems still exist, and the question is why?

Today malaria is still among the top causes of infant mortality in many African countries, including Ghana, yet we have mosquito nets, coils, sprays, long sleeved shirts that have been circulating in the country for years……and sometimes I wonder: why?

Total funding for malaria prevention and control was 2.7 billion dollars in 2016. Between 2014-2016, 582 million nets were distributed, of which 505 million were distributed in Africa, yet the number of malaria cases increased from 211 million in 2015 to 216 million in 2016 (WHO-malaria fact sheet, 2017).

I was once a supervisor for the distribution of long-lasting insecticide treated nets in rural communities. The numbers driven world saw big numbers that showed that many pregnant women were not sleeping under mosquito nets and so the solution to solve the malaria problem was to give them mosquito nets.

First, they started out by selling the nets and people would not buy them, then they offered them free to pregnant women and that did not change anything, next they distributed to families in a household and that did not change anything, and finally they implemented what is known as the hanging of long lasting insecticide treated bed nets.

This time we went into a house with a hammer, nails and ropes, and families showed us their bedroom and we hung the net for them. And yet malaria still rules. What happened with the free bed nets is now widely reported across different countries in Africa.
What do the numbers we measure mean to the people they represent?

As an example, there was a man in a small fishing village with seven children. His biggest worry was how to get food for his family. So the world of numbers develops numbers-based interventions, numbers-driven solutions. Reporters found months after the family received the mosquito nets that no one in the family slept under the mosquito nets; instead the man had sown the nets together and used them for fishing to feed his family.

Frustrations abound on both ends of the system, for public health agents and community members. Numbers act as the barrier between the two ends of the “system”, and our goal must be to break the barrier. The numbers that drive interventions can be meaningless to the community people they represent unless we engage the community and learn how our interventions can really help them.

Nu Nu Khin of Jhpiego who is working on the US PMI “Defeat Malaria Project” led by URC shares observations on the workshop being held in Yangon with national and regional/state malaria program staff to plan how to strengthen malaria interventions at the community level. The workshop has adapted Jhpiego’s Community Directed Intervention training package to the local setting.

Under supervision from health center Community Health Worker provides SP for IPTp to Pregnant Woman

Now that the World Health Organization recommends that pregnant women in high and stable malaria transmission areas receive three or more doses of Intermittent Preventive Treatment (IPTp) with Sulfadoxine-pyrimethamine, it is necessary to learn ways to reach more women with this intervention. William R. Brieger, Mathurin Dodo, Danielle Burke, Ousmane Badolo, Justin Tiendrebeogo, Kristen Vibbert, Susan J Youll, and Julie R Gutman conducted a baseline household survey of recently pregnant women in Burkina Faso to learn about the extent of current IPTp coverage and where improvements are needed. With support from the US President’s Malaria Initiative and the USAID Maternal and Child Survival Program Their findings were made available at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene.

The World Health Organization recommends intermittent preventive treatment (IPTp) to prevent the adverse effects of malaria in pregnancy in high burden settings; IPTp coverage has lagged behind international targets. In Burkina Faso, the 2014 Malaria Indicator Survey found that 22% of women received 3 or more doses of IPTp (IPTp3). In 2014, Burkina Faso’s IPTp policy was updated from recommending 2 doses to providing at least 3 doses of IPTp. Prior studies have suggested that use of community health workers to deliver IPTp can increase coverage.

To improve IPTp coverage, we will pilot community delivery of IPTp within 3 southern districts: Po, Ouargaye, and Batie. Here we report results from a baseline assessment in the selected districts. Health Management Information System (HMIS) data for 2015 were collected in each district, and IPTp3 coverage was 37%. Four health facilities per district were randomly selected to participate in the pilot. In 2017, a baseline household survey was conducted among recently pregnant women in the catchment areas of these health facilities.

Women were asked to recall the number of antenatal care (ANC) visits and IPTp doses they had received during their most recent pregnancy. The same information was extracted from their ANC cards. A total of 374 women were interviewed during the baseline survey.

ANC attendance was reported to be 98% for any visit, and 84% for four visits; these rates were 90% and 62% as documented on the ANC cards. Over 95% of women recalled receiving the first dose of IPTp, while over 80% of cards verified that the first dose was given.

Receipt of the third IPTp dose was 62% by recall and 52% as recorded on the ANC cards, while receipt of 4 doses was 32% by recall and 19% per the ANC cards. IPTp3 coverage was not associated with parity or educational level.

Following implementation of the revised IPTp policy, there has been a substantial improvement in IPTp coverage, though more work is needed to achieve the national 85% coverage target.

Our pilot will examine the impact that delivery of IPTp by community workers has on IPTp coverage, with endline surveys planned for 2018.

Justin Tiendrebeogo, Ousmane Badolo, Mathurin Dodo, Danielle Burke, and Bill Brieger of Jhpiego have designed and are implementing a study to determine the effect of delivering Intermittent Preventive Treatment for Malaria in Pregnancy through community health workers in Burkina Faso with the support of the US President’s Malaria Initiative and the USAID Maternal and Child Survival Project. They have shared the design and start-up activities for the study at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene. A summary follows:

CHW Flipchart Page

The Ministry of Health of Burkina Faso with the support of its partners initiated a study on the feasibility of increasing provision of Intermittent Preventive Malaria Treatment in pregnant women (IPTp) with sulfadoxine-pyrimethamine (SP) by involving existing community-based health workers (CBHWs). As Burkina Faso adopted the WHO recommendations for more doses of IPTp during pregnancy, it was proposed that the challenge of achieving coverage of third, fourth and additional doses could be met using CBHWs.

The approved protocol calls for CBHWs to refer pregnant women to antenatal care (ANC) to receive their first IPTp dose. Subsequent doses at one-month intervals would be provided by trained CBHWs, who would report back to supervising midwives at the ANC clinics. Several steps were taken to gain approval and set up the intervention.

CHW Using Flipchart

First, IPTp data from the health information system was gathered. IPTp coverage based on ANC registration in the 6 intervention clinics was 69% IPTp1, 68% IPTp2, 56% IPTP3, and 1% IPTp4. Similar information was obtained from the 6 control clinic catchment areas. Situation analysis found that while CBHW curriculum stresses the importance of ANC, it does not address IPTp at community level.

In response updated training materials have been developed. The study team also collected information on village size and availability of CBHWs, especially females. Among the villages in the catchment of the 6 intervention ANC clinics, 33 were found to lack female CBHWs.

Supervisory Meeting

As a result, the team needed to recruit additional female CBHWs, as revised national recruitment guidance stressed attainment of primary school certificate over gender, meaning mainly men had been hired previously. Two institutional review boards were involved and suggested the need to address the potential rare side effects of SP and concerns that community IPTp would not detract from ANC clinic attendance.

Since district and clinic level health staff will be involved in implementing the program using the national CBHW program, lessons learned from this effort to expand the work of CBHWs in preventing malaria in pregnancy should be applicable and adaptable to the whole country.

Bright Orji recently shared an overview of the Transforming Intermittent Preventive Treatment for Optimal Pregnancy (TIPTOP) Project in Nigeria, a joint venture to protect pregnant women from malaria organized by Jhpiego with support from Unitaid, the National Malaria Elimination Program, The State Ministries of Health in Ebonyi, Niger and Ondo and the local communities. He shares some highlights from the project launch this past week. The project will strengthening antenatal care services to reach out and involve communities in the grassroots delivery of intermittent preventive treatment of malaria in pregnancy (IPTp).

Among those in attendance were wife of the Ebonyi State Executive Governor and representatives from the State Ministry of Health, the State Malaria Elimination Program, the State Primary Health Care Development Agency, the Ebonyi State House of Assembly, the Ministry of Justice, the Ministry of Local Government, the Ministry of Women Affairs, the School of Nursing and Midwifery, the School of Health Technology Ngbo, the Ohaukwu local government council and the community members.

The media documented the active participation, involvement and commitment by all stakeholders. Other partners present were the World Health Organization representing all UN Agencies in Nigeria and ISGlobal of Barcelona. Furthermore, the villages, families, and traditional rulers of the 16 communities that made up Ohaukwu Communitywelcomed the new project.

In order to emphasize an integrated approach to preventing malaria in pregnancy Ebonyi State, pregnant women given long lasting nets during the TIPTOP launch

Her Excellency Rachel Umahi, wife of the Ebonyi Governor said that, “TIPTOP project came at the right time, and I pledge to join hands to stop malaria in the state.” She was joined by the Ohaukwu Local Government Chairman Barr Clement Oda who shared that, “Today marks a special day in the history of Ohaukwu LGA, Ebonyi State and Nigeria at large as TIPTOP project launch will put the state and her people in the global map. This TIPTOP project will receive a very good support and cooperation from my administration. We shall not relent on what or things we need to do to make this project a success in Ohaukwu LGA worthy for this project.”

The National Coordinator National Malaria Elimination Program, Dr. Bala Audu, explained that, “The choice of Ebonyi state and Ohaukwu LGA in particular is not unconnected with the low utilization of the antenatal care services and low performance in IPTp utilization when compared with other LGAs in the southeastern region. We hope the LGA and the state will use this opportunity to redeem her image in malaria in pregnancy performance in Nigeria.” He pledged his support to Jhpiego and the malaria programs in the three participating states.

Dr. Ugo Okoli, Deputy Country Director Jhpiego in Nigeria pointed out the synergies possible within the state through noting that the, “Maternal and Child Survival Project funded by USAID will collaborate with TIPTOP in Ebonyi State to ensure that ANC is strengthened, and communities mobilized to utilize services.”

Bright Orji will provide updates from time to time in these efforts to reduce the high mortality through community efforts from malaria in pregnancy in Nigeria.

https://t.co/yKKsmAEpSv @MinSanteRDC #Ebola 23 May 2019: Since beginning of epidemic, cumulative number of cases is 1,888, of which 1,800 confirmed 88 are probable. In total, there were 1,254 deaths (1,166 confirmed and 88 probable) and 492 people cured. 11 new confirmed cases